Monitors the overall performance of Medicare provider network development and strategy in conjunction with the BCBSMI provider network team. Develops and assists in the development of network contracting strategies on reimbursement, risk and incentive programs. Involved in service area expansion activities, including developing strategies for and negotiating with new provider networks. Must work directly with strategic leaders of the company (VP provider contracting-BCBSMI physicians and Hospital) to ensure strategic support for expansion efforts and ability to administer contract arrangements. Accountable for the production and implementation of accurate, timely and competitive contracts that reflect all applicable legislative and competitive standards. Engages providers in successful contract performance activities and oversees the monitoring of contract compliance. Develops service standards and programs to differentiate Senior Health Services from other managed care organizations. Works directly with or coordinates all matrix functions (e.g., Operations, Marketing, Utilization Management, Quality Management, and Information Services) critical to Network Development.
- Lead the Medicare provider network strategy development including resources, continued education, development and performance evaluations.
- Assist in the development of strategic initiatives relating to provider networks, including service area expansions, new payment and incentive methods, risk arrangements and new products.
- Perform analysis of the provider performance relative to Medicare metrics and develop remediation plans as necessary in conjunction with the BCBSM provider team.
- Work with BCBSMI provider team to develop and maintain a comprehensive provider network (hospitals, physicians, ancillary) that meets CMS access standards and deliver a full range of healthcare services to our members.
- Recruit, negotiate, contract and re-contract with providers to ensure quality, cost effectiveness and their participation in all products. Lead contracting efforts for new products/ risk strategies and help develop new service areas.
- Analyze, plan, and assure provider network adequately meets all CMS access standards across all geographic areas.
- Develop and implement new provider programs to improve the delivery of services for members, which are high quality and cost effective for employers.
- Develop and implement strategies for physician and hospital reimbursement.
- Communicate internally and externally regarding all provider related issues. Participate in key committees throughout the organization.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.